Working Towards ZERO Preventable Deaths

Letter from the Chairman, April 2021

Dear Readers,

On July 29th, 2005, United States President George W. Bush signed the Patient Safety and Quality Improvement Act (PSQIA) of 2005 into law. This act authorized the creation of patient safety organizations which would work with providers to improve healthcare quality and safety. The organizations were to work with healthcare providers via the collection and analysis of aggregated, confidential data on patient safety events. 

The 2005 Act directs the Secretary of the Department of Health and Human Services, in consultation with the Director of Agency for Healthcare Research and Quality (AHRQ), to write a report on effective strategies to reduce medical errors and increase patient safety and quality of care. The PSQIA also requires the draft report to be made available for public comment and submitted to the National Academy of Medicine. After these steps, the final report must be submitted to Congress, no later than December 21st, 2021. Public comments should be submitted on or before April 5th, 2021 by email at PSQIA.R[email protected].

The Patient Safety Movement Foundation is committed to continuing the work it has been doing since it was founded 12 years ago. PSMF continues to add to its internet repository of proven patient care practices in the form of Actionable Patient Safety Solutions (APSS) that ensure the safest and best quality care. These resources, which can be further updated with confirmed data, are available online for the public to review. Health care systems can use the APSS in their health care facilities.

Many healthcare systems have already instituted many of these measures and have achieved marked improvements in quality of care and safety. A good example of such a “5-Star” facility is the Children’s Hospital of Orange County, which recently instituted all of the APSS, and had zero preventable deaths in 2020.  

We are focused on tackling our goal of ZERO preventable harm and preventable deaths by 2030 in our hospitals. Transparency is key here; we can all collectively learn from mistakes. We must create an independent agency in each country to investigate medical errors and develop preventative countermeasures so that they do not occur again in any facility. These reforms can be linked to reimbursement for quality outcomes.

The ground swell for safety and quality has impacted our healthcare facilities. You can walk into many of our hospitals and see that they care about patient safety: Zero Harm posters everywhere, staff washing hands before and after visiting patients, hand sanitizers and masks available everywhere. Staff can tell you when the last retained foreign object in a surgical wound took place in their large healthcare system. Medical and surgical safety officers and teams exist that investigate all potential areas of harm and publicize the outcome so that knowledge is gained by the whole staff. This way, complete transparency with the patient and family is maintained as the investigation takes place.

Work towards ZERO harm and preventable deaths are taking place in many of our top facilities in the country and the world. Effective leadership creates high-reliability organizations from the top down. The outcomes from the COVID-19 pandemic, tragic as they have been, are contained much better (both for staff and patients) in high-reliability organizations. The introduction of electronic records linked to continuous electronic monitoring has allowed accurate information to be monitored and reviewed, with alerts issued to prevent patient harm.

The bottom line is that we have made significant advances in many of our health care systems to improve safety and quality from the top down, embrace transparency, and address errors if they occur. This makes it much easier to work towards our goal of zero preventable harm and zero preventable deaths by 2030. Health care leaders, providers, patients, the public, and politicians are all working towards this effort to ensure high quality and safe health care. 

If you would like to comment regarding the PSQIA draft report mentioned here, HHS has extended the Notice of Opportunity to Comment on the draft report regarding patient safety. Submit comments on or before April 5, 2021 to [email protected]

Mike Ramsay, M.D.
Chairman, Patient Safety Movement Foundation
Past President, Baylor Scott & White Research Institute, Dallas, TX